Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.
Data:
50-minute office session. Client presented with noticeable physical tension, including shoulders raised and arms crossed tightly. Client reported experiencing body-based reactions to certain topics, stating, "I don't even have to think about the details, my chest just gets tight and I can't breathe right." Described symptoms included tight chest, shallow breathing, and shaking hands, often occurring without conscious thoughts of trauma. Therapist explained the body's response to trauma and introduced gentle orienting and grounding techniques. Client engaged in exercises such as noticing five visible objects in the room, focusing on sensations of feet on the floor and chair support, and tracking physical sensations like chest tightness. Client's shoulders relaxed slightly during the session, and she reported feeling less stuck by the end of the session.
Assessment:
Client is making progress in building awareness of body-based trauma responses and beginning to develop tolerance for these sensations. Client responded positively to grounding and orienting interventions, showing some relaxation and reduced tension during the session. These steps align with treatment goals of increasing capacity to stay present with physical sensations safely.
Plan:
Client will practice orienting and grounding exercises daily, particularly when noticing body-based cues of threat. The next session is scheduled for next week in the office. Future sessions may focus on further developing the client's ability to regulate nervous system responses and build resilience to trauma-related sensations.
We had a 50-minute office session today. Alicia came in and right away I could see she was holding a lot of tension, shoulders up, arms crossed tight. She said she's been noticing that whenever certain topics come up, even just in passing, her body reacts before her mind does. She said quote 'I don't even have to think about the details, my chest just gets tight and I can't breathe right' unquote. She described this sense of threat that shows up in her body, tight chest, shallow breathing, sometimes her hands start shaking, even when she's not consciously thinking about the trauma.
We talked about how the body holds onto trauma, and how those sensations are the nervous system's way of trying to protect her, even when there's no actual danger in the present. I explained that we don't need to go into the details of what happened, we can work with what's happening right now in her body. We started with some gentle orienting, I asked her to look around the room and notice five things she could see, just to help her nervous system register that she's safe here in this moment. She took a few deep breaths and her shoulders started to drop a little.
Then we did some grounding work. I guided her to notice her feet on the floor, the chair supporting her, and to press her feet down gently and feel that solid contact. We went slow, checking in with her sensations as we went. Whenever she noticed her chest getting tight, we paused and just tracked it, where exactly is it, does it have a shape, does it change when you breathe into it. The goal was just to build her tolerance for those sensations without getting overwhelmed. By the end of the session, she said she felt a little less stuck in it. Her homework is to practice that orienting and grounding exercise once a day, especially if she notices those body-based cues of threat coming up. We'll meet again next week and keep building her capacity to stay present with those sensations safely.
Looking for a different note format? Quill can generate AI therapy progress notes for those too!
From even more examples, to an overview of the format in general, to templates, to a cheat sheet, here's everything you need to know about DAP notes.
Quill can write your DAP notes!
Quill Therapy Solutions uses AI to convert your session summaries into polished therapy notes. No matter the format, Quill ensures seamless integration into your workflow for only $20/month with unlimited notes.
Try generating DAP notes with Quill.
Try it for free. No credit card required.
